150 years of serving humanity
12 November 2018
Medico-Social Service of the Belarus Red Cross: whom the visiting nurses take care of and how

More than half a century ago, the visiting nurses of the Belarus Red Cross visited veterans at home for the first time. Since then, they have been helping people who have survived the war, but not only. They take care of people with disabilities and the elderly, lonely, and those whose children have left for other cities. The list of responsibilities of a visiting nurse includes a variety of tasks: measuring blood pressure, treatment of bedsores, buying food, chopping firewood, calling a plumber, just talking to a seriously ill person — all points are important here. Deputy Head of Medico-Social Department of the Belarus Red Cross Tatyana Svetlovich talks about the famous BRC Visiting Nurses Service that now has a new name – Medico-Social Service of the Red Cross.

Photos: @SRK, Monika Flückiger.

- The Visiting Nurses Service was created in 1964 for home-based patronage care of persons disabled as a result of participation in the Great Patriotic War, - says Tatyana Svetlovich. - The circle of beneficiaries expanded rapidly enough: not only war veterans, but also lonely, living alone elderly people, people with disabilities became the main category of beneficiaries of the BRC Visiting Nurses Service.

The number of visiting nurses and visiting assistant nurses reached a thousand full-time positions through government funding. They were visible in their territories and, in general, covered the needs of elderly population in home-based medico-social care. Now, when the population is aging in the world and in our country, this need is growing. In Belarus, around two million people are over 60 years old. According to the Ministry of Labor and Social Protection, as of 1st January, 2017, and 613 thousand people in Belarus are living alone elderly citizens, 134 thousand people are lonely, and many of them need medico-social care. At the same time, the number of the BRC visiting nurses service became an issue. After 2002, when the State funding of the VNS ended due to changes in the legislation, the Belarus Red Cross started to provide salaries to visiting nurses through membership fees, donations and internal sponsorship, the VNS staff reduced. Today the Service has 163 positions of visiting nurses and visiting assistant nurses. This means, best-case scenario, that there is one visiting nurse in the area, and in some areas, there is not a single position of such an important specialist.

Novopolotsk, 12.06.2018. Visiting nurse Valentina Naydenok visits her beneficiary Ivan Voronov every day. 

Although there are fewer visiting nurses now, we can talk about their improved professionalism and quality of services. This is due to cooperation with the national societies within the International Red Cross and Red Crescent Movement, and first of all, with the Swiss Red Cross, and to the involvement of international experts.

- Who can become a beneficiary in the first place?

- There are categories of beneficiaries we prioritize for service provision. These are lonely and living alone elderly citizens and people of old age, people with disabilities of group I and II. About 60% of beneficiaries have a disability; and about 44 % are beneficiaries with severe impairments in their ability to provide self-care and move. Elderly beneficiaries of the Medico-Social Service of the Red Cross are people with multiple chronic morbidity.

Novopolotsk. Ivan Voronov needs daily professional assistance in foot care. 

- And if a seriously ill person has relatives, can he/she apply for the Medico-Social Service of the Red Cross?

- The lonely are a priority. However, there are people who have relatives in other cities and married couples among our beneficiaries. For example, we provide care to such a couple in Novopolotsk. The man has a disability of group I, he had a heart attack, and he is in a wheelchair. His wife is doing a good job at home, but it is a challenge for her to leave the house, as she has serious eyesight problems. And their children and grandchildren live in Minsk. Of course, they come to visit, they have not abandoned their parents, they also help financially, but in such a situation, it is necessary to provide daily care. This care is provided by a visiting nurse, supported by a committed volunteer – a man about forty years old, with disability of group II himself, who brings out a wheelchair, takes out his beneficiary, and they walk around the city, go to the seasonal market, and buy vegetables. The beneficiary is excited when talking about it: it gives him the opportunity to feel as before.

Novopolotsk, 12.06.2018. Red Cross volunteer Vladimir Aladiev accompanies Ivan Voronov for a walk. He also takes care of other beneficiaries, including a married couple mentioned in the text. 

- What does the assistance provided by a visiting nurse include?

- The most important thing is that medico-social care provided by the Red Cross is home-based. The Service allows a person to stay at home and maintain the quality of life as much as possible. The Service uses an integrated approach, that is, provides a range of services. This includes both medical services and individual care, including hygiene, assisting in their daily needs and training in self-care; and social services: purchase of products, medicines and their delivery, communication, as well as psychosocial support, assistance in establishing contacts with other organizations and individuals – a kind of advocacy activities. Being alone at home, our lonely beneficiary is to some extent excluded from society. A visiting nurse is a bridge between the beneficiary and the life outside. This includes household services a person living alone necessarily needs: cooking food, bringing water, and chopping wood in the countryside. This range of services is unique and is not provided by any other organization.

Novopolotsk. Red Cross volunteer Vladimir Aladiev and beneficiary Ivan Voronov. 

In our country, harmonious and strong systems of public health and social protection have been created, and each of them performs its functions, but there is a gap with regard to some issues, which is not covered by certain institutions. The Red Cross is at the junction of these two systems and makes an important contribution in providing home care to seriously ill people. The Belarus Red Cross signed agreements with the Ministry of Labor and Social Protection and the Ministry of Health. At the local level, the Medico-Social Service of the Red Cross works closely with territorial health care institutions, primarily with local doctors, and with social service centers for the population.

The assistance provided by the Medico-Social Service is long-term, it is provided for about five years on average. As a rule, they provide services to the beneficiaries for the rest of their life and help them depart from this world with good grace.

An important principle of the Service is a patient-oriented approach. All services provided to the patient are based on their condition assessment and individual needs of the person. In addition, elements of case management are being introduced in our activities. A visiting nurse becomes a service coordinator. If there is a need to address custody issues, registration of disability status, or just to prescribe a medicine – often these are the responsibilities a visiting nurse takes on, and even facilitates the beneficiary to maintain contacts with their family and friends. There are many examples when a Red Cross visiting nurse involves other services to help a person. If she comes to make an injection, and notices that the tap is leaking, she calls a Housing Maintenance Service. So she addresses many issues that seem to be completely unrelated to our direct responsibilities. And I think this is unique.

Polotsk, 11.06.2018. A visiting nurse Leokadiya Ivanko came to her beneficiary Raisa Shashalevich.

A very important thing is the interaction with their immediate surrounding: relatives, friends, and neighbors. A visiting nurse is not at the patient’s all day long, she goes to visit several beneficiaries, and the beneficiaries might face problems in the evening or during the weekend. Therefore, she seeks to ensure that she has a person living close to her beneficiary with whom she can keep in touch.

An important part of a visiting nurse's work is teaching the patient to provide self-care, self-support, activation, so that a beneficiary might use the remaining skills as much as possible.

Organizationally, we are increasingly using the teamwork: a visiting nurse, an assistant nurse, and volunteers. This ensures a more efficient use of professionalism of a visiting nurse: she performs medical procedures. An assistant nurse steps in to provide individual care, and she can stay longer with the beneficiary. And volunteers take on household services, and communication. Thus, the range of services is wider, and the efficiency is higher. The teamwork contributes to the prevention of emotional burnout. This is the most efficient approach now, and we strive to make the teamwork systemic.

Polotsk, 11.06.2018. A visiting nurse Leokadiya Ivanko and her beneficiary Raisa Shashalevich.

- The approach is individual. Is there still anything typical? How often, how long does a visiting nurse stay with a person?

- After the needs assessment we draw up a plan of providing care for a specific patient, as well as a schedule of visits. Some beneficiaries need a visit every day, some - twice a day: to measure blood sugar level and inject insulin, some of them need visits twice a week, and relatives and friends help between the visits. A visiting nurse works 38.5 hours per week, the same amount as in the health care system. And this time she divides between the beneficiaries. She might spend 4 hours with one beneficiary when it is necessary to treat the bedsores, and make injections, and to provide hygienic procedures, cut hair and nails, but for some beneficiaries it is enough to measure blood pressure and make an injection today, and then go to visit another one. All days are not alike. A visiting nurse and visiting assistant nurse fill in the accounting documents, where they mark the services provided, keep a list of dynamic observation, in which they record the changes in the condition of the beneficiary. This is important to ensure continuity: for example, when calling an ambulance, this sheet can be shown to the emergency team to clarify what has been happening with the patient. Every six months, or more often if there are changes in the beneficiary’s condition, a new needs assessment is conducted and the home care plan changes.

- How many beneficiaries are provided services by the Medico-Social Service now?

- On average, about one and a half thousand people are provided services a year. As a rule, a visiting nurse provides services to 8-10 beneficiaries. However, if these patients have severe health problems (with disability of group I, who have completely lost the ability to provide self-care and movement), then they take care of 4-5 beneficiaries.

Polotsk. Red Cross volunteer Valentina Tkachuk helps Raisa Shashalevich in the household.

- How to become a beneficiary of the Medico-Social Service of the Red Cross?

- The local health care institutions and territorial social services centers play a major role since they can refer people to the Red Cross. Often, relatives of people in need apply or beneficiaries can apply personally.

The Belarus Red Cross provides free of charge assistance to the needy people. Various sources of funding allowed for this: until 2002, it was the state budget and financial assistance from the Swiss Red Cross and the International Federation of Red Cross and Red Crescent Societies. From 2002 to 2013, the Service operated solely due to membership fees, donations, and internal sponsorship. In 2012, a new edition of the Law on Social Services was adopted and a state social contracting mechanism was introduced, which allows non-profit non-governmental organizations to be involved in the provision of social services based on state funding from the local budget. It is carried out on a competitive basis. Local authorities make an analysis of the socio-demographic situation in the district, identify the priority needs of the population, and determine the amount of financial resources that can be allocated for the state social contracting. Then the terms of reference for social services or projects is drawn up, followed by a competitive tender, and the service providers are selected. The Belarus Red Cross actively participated in the initiative on development and implementation of the state social contracting in Belarus and became a pioneer in its implementation. In 2013, a competitive tender on provision of medico-social care services was held in Grodno, one position of a visiting nurse was financed, and this was the testing of a new system. Since then, we have implemented 137 state social contracts to provide services to the needy categories of the population. Every year the number of the needy grows and the geography expands: in 2017 all the regions and the Minsk city, and more than 50 districts have been already involved.

Polotsk. Red Cross volunteer Valentina Tkachuk and her beneficiary Raisa Shashalevich. 

- What other legislative amendments have been made or are being developed with the participation of the Belarus Red Cross?

- The Belarus Red Cross took part in the development of amendments to legislative acts regulating the use of the state social contracting to address implementation challenges thereof. Last year, a new Resolution of the Council of Ministers was adopted, with important amendments to facilitate the use of the state social contracting locally. Not only has the geography of the state social contracting  expanded, but also the application of this mechanism to other services for other categories of people in need has expanded since 2017. We talked more about social services, but new legislation was passed, which allowed for the implementation of the activities of the state program “People’s Health and Demographic Security” for 2016-2020 in terms of HIV prevention. The state social contracting on HIV prevention and harm reduction is already working. The Medico-Social Service of the Red Cross provides home-based care, medical and palliative care services to people living with HIV. We have first experience with this in four districts of Gomel region.

There is an issue of social inclusion of ex-prisoners, and Ministry of the Interior is doing a lot of advocacy work in this regard. Perhaps the next step will be the state social contracting in this area. Legislation is being gradually developed and improved.

- Who comes to work for the Medico-Social Service and who stays with it?

- All our visiting nurses are people with secondary medical education. There are quite a lot of part-timers from state health institutions, especially in rural areas, but we support this and we are happy about it. For assistant nurses, there are no educational requirements, but we provide the Red Cross training. Often the volunteers become assistant nurses afterwards. In the early 2000s, there were many elderly visiting nurses in the Service. Now the situation is changing, and young visiting nurses join it.

Polotsk, 11.06.2018. Ludmila Zavedeeva, a visiting nurse, came to her beneficiary Nina Shinkevich. 

- What additional training does a visiting nurse get?

- We have special internal training with a systemic approach: any visiting nurse who joins the Red Cross gets basic training in home-based care skills. There are trained trainers and instructors to train all new visiting nurses, relatives, and close relatives of seriously ill people. Being a part of the International Red Cross and Red Crescent Movement, we can use the experience of other National Societies that share innovative methods of care provision for seriously ill people. In particular, with the support of experts, kinaesthetics (methodology based on the use of human movement competences) was introduced in the BRC. This approach allows to save or partially return to persons with serious illness their own movement skills, and to keep the health of a caregiver. With the support of international experts, trainings were conducted in home care, prevention and treatment of chronic wounds including bedsores and trophic ulcers. Extensive practical experience with seriously ill patients is also of great importance. In terms of home care for seriously ill patients, our nurses are far above the primary health care nurses.

- What are the standards applied in the work of visiting nurses?

- We have always had internal standards, and we have them now. This year, the Belarus Red Cross initiated the establishment of the Ministry of Health working group with our participation in developing standards for medico-social home-based care. We are working on a draft regulation: we have compiled a single list of services, developed an algorithm for the provision of each service, and determined the time schedule and consumables rate. The Belarus Red Cross has prepared a proposal to change the definition of medico-social care in the Health Care Law. In the Law it is formulated as “assistance to people who need round-the-clock monitoring and care,” that is, it refers more to inpatient care. We have proposed a change and addition that will cover “home care”.

Polotsk. The beneficiary of the Medico-Social Service of the Red Cross Nina Shinkevish needs home-based care after a stroke.

- What are the prospects for the development of the Service?

- Our main goal is to help more people in need of home-based care. That is, to increase the number of staff of the Medico-Social Service of the Red Cross, so that the Service could work in each district and provide medico-social home-based care to those in need nationwide.

A very important issue is ensuring the sustainability of the Medico-Social Service of the Red Cross, so that it could work constantly, regularly and provide high quality services. Many efforts have been made to develop a fundraising strategy to rely on not only membership fees and international donations, but also to increase the amount of internal sponsorship.

From this year on, we plan to start providing paid services to the public. Many relatives and friends of seriously ill people apply to the Red Cross for the provision of medico-social care. People say they are ready to pay for these services. The big problem is that working people have to take a sick-list and vacation, go half-time or quit their jobs altogether in order to care for a sick relative. This affects the economy.

We are going to develop two directions on a paid basis: training in basic home-based care with elements of kinaesthetics and provision of medico-social home-based care. For this, the Belarus Red Cross decided to establish a unitary enterprise that will provide such services free of charge – first in Grodno and Vitebsk, and then in other regions. The profit will be used for expanding free of charge assistance to those who need medico-social care, but do not have sufficient funds. Thus, those who apply to us will have the opportunity to help both their close relatives and the most needy.